Educating Athletes and Coaches about Female Triad Syndrome

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The Female Athlete Triad is a syndrome consisting of an energy deficiency, menstrual disturbance and bone loss. Energy deficiency results when you expend more calories than you consume, and there is no fuel to feed your body. This leads to missed or absent periods/amenorrhea and low bone density. The triad is a spectrum and not everyone who is affected has the same degree of symptoms, however energy deficiency is the common symptom.

Female athletes might be unintentionally or intentionally not feeding their bodies. In high level athletes, the calorie requirement can be high. On the other hand, body image issues and the drive for thinness can lead to disordered eating and sometimes to eating disorders. The calorie deficit leads to a disruption in hormones lowering estrogen production and causing menstrual dysfunction. It also affects the calcium in the bone resulting in decreased bone mass and bone matrix deterioration and increased fracture risk.

Menstrual history needs to be assessed in female athletes. As the doctor to an athlete you need to ask about missed periods, irregular periods, decreased periods and a lack of period all together. Athletes might not feel comfortable discussing it openly, and they might not be concerned with a lack of, or small period. It is often up to the coach, the parent or the doctor to ask the athlete. An athlete does not have to be amenorrheic to be diagnosed with the female athlete triad.

Decreased bone health is due to lack of estrogen and can lead to osteopenia and osteoporosis. An athlete with the female athlete triad can lose up to 2 percent bone mineral density (BMD) per year. A teenager with normal menstrual history would be increasing bone mass by 2-4 percent a year. The loss of bone health can lead to stress fractures, osteoporotic fractures, and other injuries. The teen years are important for bone health later in life. Lost BMD might never be regained and might follow the girls through life. Bone is constantly being taken up and remade. When nutrition is not adequate, bone is not being redeposited and it can lead to stress fractures, and weaker bones.

What exactly is disordered eating?

Disordered eating is any abnormal eating pattern. It can be restricted eating, binge eating, compulsive eating, and it can be increasing workouts because of what you have eaten. Disordered eating is not an eating disorder, but can lead to an eating disorder, especially in athletes. Body image and poor self esteem is an important issue with young girls and many women. It is not always behind the calorie restriction, but often times it is. As a female, I understand the societal pressure for thinness, the ideal body type, the pressure to look a certain way. As an athlete, especially in those sports where appearance and leanness are important, you have a drive to be the best and look the best. I also understand that if I do not eat enough, performance will suffer.

As a doctor, I see the importance of education: educating the family, coaches and girls on their eating and the importance of eating, and sometimes limiting their exercise. It is important to remove the pressure of achieving an unrealistic low body weight from the athlete in sports where appearance and leanness are important. Pre competition “weigh-ins” should also be discouraged. Diet is the key! A well balanced diet consisting of fat, protein and carbohydrates will lead to more energy and often better performance.

It is important to be aware of female athletes whether you are their parent, coach, or doctor: monitor weight gain/loss, increasing injury frequency, and ask about periods. Asking the questions can help diagnose early so you can start replacing calories and in some cases start hormone replacement. Please make sure to talk to a doctor if concerned. A nutritionist and counselor can also be great resources.

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